Provider Demographics
NPI:1700986965
Name:HICKS, THOMAS GLENN (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:GLENN
Last Name:HICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 COLUMBIA AVE W
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-3028
Mailing Address - Country:US
Mailing Address - Phone:269-965-4500
Mailing Address - Fax:269-965-1150
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:BOX 42
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-341-6417
Practice Address - Fax:269-341-8743
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301035006208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C910950OtherBCBSM
MI1700986965Medicaid
MITH035006OtherBCBCN
MI0C910950OtherBCBSM
MITH035006OtherBCBCN
OM31600003Medicare ID - Type Unspecified